Chapter 2 Quality and Evidence-Based Respiratory Care Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Learning Objectives  Describe the elements that constitute quality respiratory care.  Explain methods used for monitoring the quality of respiratory care provided.  Explain how respiratory care protocols enhance the quality of respiratory care services.  Define disease management.  Describe evidence-based medicine. 2 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Elements of a Respiratory Care Department  Medical Director  Responsible for clinical function of department  Usually is pulmonologist or anesthesiologist  Must possess both management & clinical skills 3 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Elements of a Respiratory Care Department (cont.)  Medical Director (cont.) 4 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Responsibilities of the medical director of Respiratory Care include all of the following except: A.educating the medical and nursing staff regarding respiratory therapy B.participating in the preparation of the department budget C.organizing the weekly work schedule D.participating in respiratory care in-services and training programs 5 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Elements of a Respiratory Care Department (cont.)  Respiratory Therapists  Quality of RT department depends on education, experience, & professionalism of therapists  RTs are primary source of quality care provided by department 6 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Credentialing in Respiratory Care  Quality RC departments are staffed with RTs who hold appropriate credentials  To be eligible for credentialing, individuals must graduate from CoARC-approved educational programs  Graduates can then sit for certification & registry exams offered by National Board for Respiratory Care (NBRC) 7 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Professionalism 8 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Technical Direction  Quality respiratory care depends on strong leadership  Manager of department usually provides technical direction  This person oversees policies, procedures, & equipment used to provide safe & effective patient care 9 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Methods to Enhance Quality Respiratory Care  Respiratory Care Protocols  Put in place to enhance appropriate allocation of respiratory care services  Represent guidelines to deliver care only when indicated, by correct method; discontinued when no longer needed 10 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Respiratory Care Protocols 11 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Respiratory Care Protocols 12 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Respiratory Care Protocols 13 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Respiratory Care Protocols (cont.) 14 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

According to respiratory care protocols, what is the minimum frequency for assessing patients for a change in clinical status? A.Every other day B.Every 4 hours C.Once per shift D.Once a day 15 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Standardized Assessment 16 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Care Plan 17 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Monitoring Quality Respiratory Care  After all elements are in place, quality respiratory care is maintained by monitoring  One method to monitor quality of care provided : seek voluntary accreditation  Accreditation by The Joint Commission is most important 18 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Monitoring Quality Respiratory Care (cont.)  Current Joint Commission standards call for continuous quality improvement (CQI)  CQI is an ongoing process to detect & correct factors hindering quality care  AARC has developed 4 goals that should be included in CQI plan 19 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Monitoring Quality Respiratory Care (cont.) 20 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Monitoring Quality Respiratory Care (cont.)  Competencies or “checks”: used to test skills & knowledge through use of clinical simulations  Used mainly for procedures that carry degree of patient risk  Examples: arterial puncture, aerosol therapy, BiPAP set up, intubation, & ventilator management  Simulated patient scenarios help determine consistency among RTs 21 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Skill Checklist 22 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Monitoring Quality Respiratory Care (cont.)  Peer Review Organizations  Federal government established elaborate system of PROs to evaluate quality of care given to Medicare beneficiaries  Such PROs evaluate care provided to individuals in real time to ensure compliance with federal guidelines  Accountable Care Organizations (ACOs): emerging groups of health care providers  ACO’s work to enhance quality of care, receive payments, & lower costs 23 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Care Plan Audit 24 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Hospital Restructuring & Redesign  An attempt to do more patient care w/ less overhead  Common approaches include:  Cross-training employees  Using unlicensed assistive staff  Decentralizing services (patient-focused care) 25 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Disease Management  Refers to organized strategy of delivering care to large group of individuals w/ chronic disease to improve outcomes & reduce costs  Disease management programs may be developed for patients with asthma, diabetes, chronic obstructive pulmonary disease (COPD), or congestive heart failure (CHF) 26 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

All of the following are the goals of disease management,except: A.Reduce costs B.Develop new strategies C.Keep track of medication usage D.Improve outcome of individuals with chronic diseases. 27 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Evidence-Based Medicine  Represents important concept regarding quality respiratory care  Refers to determining optimal clinical management based on evidence found in scientific literature  Scientific literature publishes best scientific evidence available  Best scientific evidence includes rigorous clinical trials to support most appropriate & correct clinical decisions  Clinical Practice Guidelines (CPGs) developed by AARC represent recommendations based on expert review of evidence 28 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

The goal of evidence - based medicine is to: A.use results from research for clinical practice B.use literature based research only for new medications C.develop new treatments from a single case report D.disregard older case studies and only focus on more current ones 29 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Evidence Based Medicine (cont.)  Evidence comes from 4 different types of studies: 1.Single case studies ( simplest, least rigorous) 2. Case series (collection of patients with similar clinical features) 3. Cohort studies (comparing 2 groups, greater scientific rigor) 4. Randomized controlled trials (ideal, most rigorous evidence)  Through these studies, new treatments, medications, & new modes of ventilation have been designed 30 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Evidence Based Medicine (cont.)  For study to be successful, key outcomes are:  Survival  Discharge from ICU  Organ system failures  Meta-Analysis is additional tool of evidence- based medicine:  Identifies, analyzes, & summarizes body of literature for specific topic being studied 31 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Evidence Based Medicine (cont.) 32 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

What type of study holds the most scientific rigor? A.single patient studies B.cohort studies C.case series D.randomized controlled trials 33 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.